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Intensity of Aphasia Therapy, Impact on Recovery

Sanjit K. Bhogal, BA (Hon); Robert Teasell, MD; Mark Speechley, PhD

Background —It has been speculated that the conflicting results demonstrated across poststroke aphasia therapy studiesmight be related to differences in intensity of therapy provided across studies. The aim of this study is to investigate the

relationship between intensity of aphasia therapy and aphasia recovery.

Methods—A MEDLINE literature search was conducted to retrieve clinical trials investigating aphasia therapy after stroke.

Changes in mean scores from each study were recorded. Intensity of therapy was recorded in terms of length of therapy,

hours of therapy provided per week, and total hours of therapy provided. Pearson correlation was used to assess the

relationship between changes in mean scores of outcome measures and intensity of therapy.

Results—Studies that demonstrated a significant treatment effect provided 8.8 hours of therapy per week for 11.2 weeks

versus the negative studies that only provided 2 hours per week for 22.9 weeks. On average, positive studies provided

a total of 98.4 hours of therapy, whereas negative studies provided 43.6 hours of therapy. Total length of therapy time

was found to be inversely correlated with hours of therapy provided per week (P0.003) and total hours of therapy

provided (P0.001). Total length of therapy was significantly inversely correlated with mean change in Porch Index of

Communicative Abilities (PICA) scores (P

0.0001). The number of hours of therapy provided in a week wassignificantly correlated to greater improvement on the PICA (P0.001) and the Token Test (P0.027). Total number

of hours of therapy was significantly correlated with greater improvement on the PICA (P0.001) and the Token Test

(P0.001).

Conclusions—Intense therapy over a short amount of time can improve outcomes of speech and language therapy for

stroke patients with aphasia. (Stroke. 2003;34:987-993.)

Key Words: aphasia cerebrovascular accident therapy treatment outcome

The Agency for Health Care Policy and Research Post-

Stroke Rehabilitation Clinical Practice Guidelines1 de-

fine aphasia as “the loss of ability to communicate orally,

through signs, or in writing, or the inability to understandsuch communications; the loss of language usage ability.”

Darley2 noted that aphasia is generally described as an

impairment of language resulting from focal brain damage to

the language-dominant cerebral hemisphere. This serves to

distinguish aphasia from the language and cognitive-

communication problems associated with non–language-

dominant hemisphere damage, dementia, and traumatic brain

injury.3 However, defining aphasia as purely a disorder of

language may oversimplify a complex clinical entity.

Kertesz4 clinically described aphasia as a “neurologically

central disturbance of language characterized by paraphasias,

word finding difficulty, and variably impaired comprehen-

sion, associated with disturbance of reading and writing, attimes with dysarthria, non-verbal constructional and problem-

solving difficulty and impairment of gesture.”

The most effective means of treating aphasia after stroke

has yet to be determined, and studies investigating the

efficacy of speech and language therapy (SLT) for patients

See Editorial Comment, page 992

suffering aphasia after stroke have yielded conflicting results.

One possible explanation for the observed heterogeneity of findings across studies is a difference in intensity of thera-

py.5,6 We have noted that the failure to identify a consistent

benefit might have been due to the low intensity of SLT

applied in the negative studies, whereas higher intensities of

therapy were present in positive studies.7 A meta-analysis that

included all patients suffering from aphasia, not just stroke

patients, revealed that the more intensive the therapy, the

greater the improvement.8

The objective of the present study is to investigate the

relationship of intensity of aphasia therapy and aphasia

recovery after stroke. Using published studies of SLT, this

study attempts to quantify treatment intensity and determine

whether, in fact, intensity correlates with outcome results.

Methods

Study Identification and SelectionA MEDLINE literature review was conducted to identify controlledtrials that investigated SLT for aphasia after stroke published

Received July 2, 2002; accepted October 22, 2002.From the Department of Physical Medicine and Rehabilitation (S.K.B., R.T.) and Department of Epidemiology and Biostatistics (M.S.), University of

Western Ontario, and St Joseph’s Health Care London (S.K.B., R.T.), Parkwood Hospital, London, Ontario, University of Western Ontario, London,

Ontario, Canada.Correspondence to Dr Robert Teasell, 801 Commissioners Rd East, London, Ontario N6C 5J1, Canada. E-mail [email protected]

© 2003 American Heart Association, Inc.Stroke is available at http://www.strokeaha.org DOI: 10.1161/01.STR.0000062343.64383.D0

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between January 1975 and May 2002. All searches used the limitterms human, adult , and English. The following MEDLINE searchwords were used: aphasia, stroke, speech therapy or languagetherapy or speech and language therapy, and treatment , as well asthe combined exploded key words stroke and aphasia and speechtherapy or language therapy or speech and language therapy andtreatment .

Articles identified in the MEDLINE literature search were in-

cluded in the present analyses if the study compared conventionalSLT with treatment of a comparative control group. If the compar-ative control group underwent an altered form of conventional SLT,then the duration of that therapy had to be of the same duration as theSLT. Articles were limited to stroke survivors suffering from aphasiaafter stroke, and studies that included patients with traumatic braininjury or any other disorders or illnesses were excluded. Studies thatprovided a drug and/or placebo as an adjunct to therapy were alsoexcluded from the present review.

After each citation was identified through the literature search, asingle investigator (R.T.) reviewed the corresponding abstract toassess the suitability for inclusion. All articles that appeared to betreatment based were considered. The article was examined a finaltime by the study coordinator to verify that at least 1 treatmentintervention had been assessed. Five studies were eventually deemedsuitable for inclusion. Studies cited in review articles and in retrieved

articles but not identified through the MEDLINE search were alsosought. Five more articles were found this way, bringing the totalnumber of articles meeting the inclusion criteria to 10.

Data AbstractionSeveral independent reviewers were used to extract data from theselected studies. Two abstractors, each blinded to the other’s results,reviewed each article independently. The review process consisted of the following 2 parts. (1) First, data were collected pertaining tostudy methodology, identification of outcome measures, results, andfinal conclusions. Data were typed into a computer-generated formto avoid identifying the abstractor via handwriting. (2) A qualityrating score was assigned. The quality rating scale used was thePhysiotherapy Evidence Database (PEDro) scale, developed by theCentre for Evidence-Based P hysiotherapy in A us tralia

(http://www.pedro.fhs.usyd.edu.au/).PEDro was developed for the purpose of accessing bibliographicdetails and abstracts of randomized controlled trials, quasirandom-ized studies, and systematic reviews in physiotherapy. Studiesincluded in this review using a nonexperimental design could not beassigned a PEDro score and were given a designation of no score.The PEDro Scale consists of 10 quality ratings, each receiving eithera yes or no score. The maximum score a study could receive was 10.Two independent raters reviewed each article, and a third reviewerresolved any scoring discrepancies between the 2 raters. The scoreprovided by the third reviewer constituted the final PEDro score.

Statistical AnalysisThe abstracted data (treatment type, length of therapy period in hoursand weeks, and mean change in scores for outcome measures) wereentered into SPSS 10.1 for Windows. An independent t test was usedto determine differences of mean scores and length of treatmentbetween the studies yielding positive results and those yieldingnegative results. Pearson bivariate correlation was used to determinethe association between mean change in scores for outcome mea-sures and the intensity of therapy (length of therapy period and hoursof therapy provided per week).

Several articles presented their results graphically. The graphsfrom these articles were scanned and entered into Microsoft Paint as.jpg files. The bitmap coordinates of the graphs were then recorded,and the individual values estimated relative to the bitmap coordinatesof the y axis.

Results

Summary of Individual Studies

Ten studies investigating the SLT for stroke patients sufferingfrom aphasia met criteria after being reviewed. These 10

studies represented 864 individual patients. A brief descrip-

tion of each article follows.

Meikle et al9 compared the progress of 31 acute stroke

patients with dysphasia receiving conventional speech ther-

apy from either a qualified speech therapist or a nonprofes-

sional volunteer. Patients received a minimum of 3 and a

maximum of five 45-minute sessions per week. Length of

treatment was not defined, and therapy sessions were discon-

tinued when the therapist felt that the patient had not

improved in 2 consecutive sessions. There were no significant

differences in treatment results between the 2 groups. Both

treatment regimes appeared to provide the same benefits.

David et al10 compared the effects of speech therapists and

untrained volunteers on recovery from aphasia in the acute

phase after stroke. One hundred fifty-five patients received 30

hours of therapy over 15 to 20 weeks. Although patients in

both treatment groups improved, there was no overall differ-

ence in the amount of progress between the groups. However,

patients who were referred to treatment late (the median

interval between onset of stroke and starting treatment was 20weeks) began treatment at a level similar to that of the other

patients and showed an identical recovery pattern. This

suggested that treatment, and not spontaneous remission, was

responsible for the majority of the improvement experienced

in these patients.

Lincoln et al11 examined whether speech therapy produced

a better language outcome than natural recovery alone in 327

acute stroke patients with aphasia. Patients in the treatment

group received two 1-hour sessions of therapy per week for

24 weeks. Comparison of group results on the Porch Index of

Communicative Abilities (PICA) and the Functional Com-

munication Profile (FCP) revealed no significant difference

between treated and nontreated patients. Thus, speech therapydid not improve language functioning more than what was

achieved by spontaneous recovery. The treatment regime that

was used, which was representative of clinical practice, was

determined not to be effective for aphasic patients.

Shewan and Kertesz12 investigated 3 types of speech

therapy and compared its effects in 100 acute aphasic stroke

patients who received no speech or language therapy. Patients

who recovered their language skills within 2 to 4 weeks after

onset were excluded from the study. Treatment was provided

in three 1-hour sessions per week for 1 year. Shewan and

Kertesz12 noted no difference in Western Aphasia Battery

scores, its subsets Language Quotient (LQ) and Cortical

Quotient (CQ) scores, or the Auditory Comprehension Test

for Sentences scores, between groups. When treated patients

were compared with controls, Language Quotient scores of

patients in the treatment groups were significantly higher

compared with the control groups. Individually, the language-

oriented therapy and stimulation-facilitation therapy patients

significantly improved compared with the control patients,

but no significant differences were observed between the

unstructured-settings group and the control group. In addi-

tion, the CQ scores of the treatment groups were significantly

higher compared with patients in the control group. Individ-

ually, stimulation-facilitation therapy patients had higher CQ

scores than the controls, but the language-oriented therapyand unstructured-settings groups were not significantly dif-

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ferent from the controls. The authors of this study suggested

that comparisons of treated patients with untreated aphasic

patients demonstrated that treatment was a significant factor

in improvement.Wertz et al13 compared the efficacy of clinic, home, and

deferred language treatment for aphasia in 121 patients

between 2 and 24 weeks after onset. Patients received 8 to 10

hours of therapy a week for 12 weeks. The authors noted that

at 12 weeks, clinic-treated patients made significantly more

improvement on the PICA than did the deferred patients,

whereas improvement in the home-treated patients did not

differ significantly from either the clinic-treated or deferred-

treatment patients. At 24 weeks, no differences were noted on

the PICA between all groups. On the basis of these results,

Wertz et al13 concluded that clinic treatment for aphasia was

efficacious, and delaying treatment for 12 weeks did not

compromise the ultimate improvement in aphasic patients.Hartman and Landau14 compared conventional speech

therapy provided by professional speech pathologists with

emotional supportive counseling therapy in 60 stroke patients

1 month after onset. Therapy was provided twice a week for

6 months. Change scores on the PICA revealed no significant

differences between the groups. Hartman and Landau14 as-

serted that conventional speech therapy was no more effec-

tive than emotional support.

Brindley et al5 investigated the speech of 10 patients with

chronic Broca’s aphasia after intensive speech therapy. Pa-

tients were provided 5 hours of therapy over 5 days a week

for 12 weeks. There was significant improvement on the FCP

subscales in movement, speech, reading, and overall score

during the intensive period. There was a significant ratio of

improvement (ratio of the score at the end of a period to that

at the start) on FCP between the intensive period and a second

nonintensive period in movement, speech, and overall score.

In addition, the Language Assessment Remediation and

Screening Procedure showed significant improvement during

the intensive period on sentence length increase, a reduction

in element omission, and an increase in percentage of full

utterances. Thus, the authors of the study concluded that

intensive therapy improves speech recovery 1-year after onset

of aphasia for some patients.

Marshall et al15

investigated the impact of home treatmentfor 121 aphasic patients between 2 to 24 weeks after onset by

trained nonprofessionals. Patients received 8 to 10 hours of

therapy a week for 12 weeks at 2 to 24 weeks after onset. The

authors observed that at 12 weeks the SLT group showed

significantly more improvement than the deferred-treatmentgroup. However, improvements noted in the home-treatment

group did not differ from those in the SLT group. The authors

further noted that at 24 weeks, the deferred-treatment group

caught up to the other 2 groups and no significant differences

between the groups were observed.

Poeck et al6 evaluated the outcome of intensive language

treatment in 160 acute and chronic aphasic inpatients. Patients

undertook 9 hours of therapy a week for 6 to 8 weeks. These

patients were compared with a group of aphasic stroke patients

who received no aphasia therapy. The authors of the study

observed that the mean gain on each measure of the Aachen

Aphasia Test improved substantially for both the treated and the

control group. However, with intensive therapy, 78% of the

patients treated up to 4 months after onset versus 46% of the

patients treated from 4 to 12 months after onset improved

beyond that expected with spontaneous recovery.

Prins et al16 compared the effectiveness of systematic

aphasia therapy that was organized on 4 levels (nonverbal,

phonology, lexical semantics, and morphosyntax) with the

effectiveness of conventional therapy. Thirty-two stroke pa-

tients exhibiting aphasia for at least 3 months were included

in the study. Patients receiving systematic aphasia therapy

were compared with aphasic stroke patients receiving con-

ventional SLT and with patients receiving no aphasia therapy.

Patients in this study received only 2 therapy sessions perweek for 5 months. Multiple regression analysis revealed that

there were no significant differences between the groups on

all evaluations. Moreover, neither the systematic aphasia

therapy nor the conventional therapy had any effect on the

recovery progress of the study patients.

Of the 10 studies reviewed, 5 were positive studies and 5

were negative studies (see Table 1). When examining the

outcomes related to the amount of therapy provided, it

appears the positive studies provided an average of 7.8 (5 to

10) hours of therapy per week for 18 (8 to 12) weeks

compared with the negative studies that only provided 2.4

(2 to 3.8) hours per week for 22.9 (20 to 26) weeks.Moreover, total number of hours of therapy was, on average

TABLE 1. Intensity of Aphasia Therapy Poststroke and Its Impact

Authors, Year PEDro Score

n at

Randomization Intensity of Therapy

Impact of Aphasia

Therapy vs Control

Lincoln et al, 1984 6 327 Two 1-hour sessions per week for 34 weeks

Wertz et al, 1986 6 121 8 to 10 hours a week for 12 weeks

Marshall et al, 1989 6 121 8 to 10 hours a week for 12 weeks

Hartman and Landau, 1987 6 60 2 times a week for 6 months

David et al, 1982 5 155 30 hours over 15 to 20 weeks

Shewan and Kertesz, 1984 5 100 Three 1-hour sessions a week for 1 year

Prins et al, 1989 5 32 2 sessions a week for 5 months

Meikle et al, 1979 4 31 Minimum of 3 and maximum of 5 sessions a week of 45 minutes

Brindley et al, 1989 4 10 5 hours over 5 days a week for 12 weeks

Poeck et al, 1989 Not scored 160 9 hours a week for 6 to 8 weeks

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108 (60 to 156) hours in the positive studies versus only 43.6

(30 to 52) hours in the negative trials.

Relationship Between Intensity of TherapyProvided and Outcome of StudyWe next wanted to determine whether there was in fact a

correlation between intensity of therapy provided and the

outcome of a study. The target outcome measures were the

Token Test, PICA, and FCP, which were the scales most

often used by the reviewed studies. The Token Test, PICA,

and FCP were used in 3, 4, and 3 studies respectively. As

such, Shewan and Kertesz,12 a positive study, was excluded

from the analysis because this study did not use any of the

targeted outcome measures. Although Meikle et al,9 a nega-

tive study, did use the PICA, the authors did not provide point

measures or measures of variability of their results; therefore,this study was excluded from our analysis. Two studies

provided their results in graph format.10,11 The bitmap coor-

dinates of the mean scores from these studies were recorded

and their values calculated relative to the bitmap coordinates

of the y axis.

Eight studies, therefore, provided the appropriate data to

allow determination of the relationship between intensity of

therapy provided and outcome (see Table 2). Four studies

yielded positive results,5,6,13,15 and 4 yielded negative

outcomes.10,11,14,16

Of the 4 positive trials analyzed,5,6,13,15 intensive practice

(mean, 8.8 hours a week) was provided over a short amount

of time (mean, 11.2 weeks), thereby accumulating an averageof 98.4 hours of total therapy time. In the 4 negative studies

analyzed,10,11,14,16 less intense practice (mean, 2.0 hours a

week) was provided for a longer duration (mean, 22.9 weeks),

accumulating an average of 43.6 hours of total therapy time

(see Table 3). In the positive studies, significantly more hours

of therapy per week and significantly more total therapy

hours in a significantly shorter period of time were provided,

as compared with the negative studies.

Total length of therapy time was inversely correlated with

hours of therapy provided per week (r 0.639, P0.003,

n19). Moreover, hours of therapy provided in a week was

significantly correlated to total hours of therapy provided

(r 0.542, P0.016). In other words, the shorter the overall

therapy period was, the more hours of therapy provided in a

week. The more hours of therapy provided per week, the

greater the total hours of therapy provided over the study’s

duration. Stated differently, in studies in which the overall

length of treatment was shorter, the therapy was more

intensive. As such, the positive studies, which were signifi-cantly shorter in duration, were more intensive than the

negative studies, which were longer in duration.

The positive studies demonstrated a mean improvement in

both the PICA13,15 and Token Test6,15 scores of 15.13 (SD,

3.06) and 13.74 (SD, 8.67), respectively. The negative studies

demonstrated mean improvement on the PICA11,15 and Token

Test16 scores of 1.37 (SD, 0.52) and 0.59 (SD, 0.78),

respectively (see Table 3). The mean improvements in both

PICA and Token Test scores were significantly different

between the positive and negative resultant studies (see Table 3).

Brindley et al5 provided their results in terms of ratio of

improvement (ratio of the FCP scores at the end of treatment

period to the FCP at the start). A ratio of 1 indicates animprovement, whereas a ratio of 1 indicates decline over

time. Because change scores could not be retrieved from this

article,5 we decided to convert the FCP scores of David et al10

TABLE 2. The 8 Studies Analyzed for Association Between Intensity of Therapy

and Aphasia Recovery

Study

Hours per

Week

Therapy Length

(weeks)

Total Hours

of Therapy

Measures

Used

Impact of

Therapy

David et al10 20 30 FCP

Lincoln et al11 2 24 48 PICA

FCP

Wertz et al13 10 12 120 PICA

Hartman and Landau14 2 26 52 PICA

Brindley et al5 5 12 60 FCP

Marshall et al15 10 12 120 PICA

Token Test

Poeck et al6 9 8 72 Token Test

Prins et al16 2 22 44 Token Test

TABLE 3. Comparing Intensity of Therapy Between Positive and Negative Resultant Studies

Therapy Measures Mean (SD) Outcome Measures Mean (SD)

Length (weeks) Hours (per week) Total (hours) PICA Token Test

Positive studies n259 11.2 (1.7) 8.8 (2.0) 98.4 (28.2) 15.1 (3.1) 13.74 (6.67)

Negative studies n574 22.9 (2.3) 2.0 43.6 (8.3) 1.37 (1.37) 0.59 (0.79)

t statistic 12.80 8.72 5.61 8.79 2.561

P value 0.001 0.001 0.001 0.001 0.05

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and Lincoln et al11 to ratio factors as well. Brindley et al5

noted a significant ratio of improvement on overall FCP

scores between groups (1.10 versus 0.97, P0.01), whereas

the ratio of improvement on FCP scores was not significant

between groups in the David et al10 (1.54 versus 1.53) and

Lincoln et al11 (1.14 versus 1.14) studies. As such, the mean

ratio of improvement in FCP for group in the negative

trials10,11 was 1.34 (SD, 0.23), whereas for the positive trial5

it was 1.04 (SD, 0.09). The difference in scores between the

negative and positive trials was not statistically significant(P0.16). Because no significant differences in FCP scores

were noted between the negative and positive trials, no

further analysis using the FCP was attempted.

Analysis revealed that the total length of therapy was

significantly inversely correlated with mean change in

PICA11,13,14,15 scores (r 0.948, P0.0001, n9). That is,

the shorter the therapy period, the greater the change in PICA

scores. This trend was also evident when we looked at the

Token Test6,15,16 change scores, (r 0.581, P0.17, n7),

although it failed to achieve statistical significance (see Table

4). In addition, the hours of therapy provided in a week was

significantly correlated to greater improvement on the PICA

(r 0.957, P0.001, n9) and on the Token Test (r 0.811,P0.027, n7).

As noted earlier, total hours of therapy received was

significantly greater in the shorter, more intense studies that

provided positive results compared with the negative result-

ant studies. Total hours of therapy were significantly corre-

lated with mean change in PICA (r 0.958, P0.0001, n9)

and Token Test scores (r 0.963, P0.0001, n7). As such,

the more hours of therapy provided, the greater the improve-

ment in PICA and Token Test scores noted.

DiscussionFour of the 8 reviewed studies that reported significantly

positive results5,6,13,15 provided an average of 8.8 hours of

therapy per week for 11.2 weeks compared with the 4

negative studies10,11,14,16 that only provided approximately

two 1-hour sessions per week for 22.9 weeks. Analysis

revealed that the more intensive therapies (those that pro-

vided greater hours of therapy per week) resulted in the

improved outcomes. Significant improvement in PICA and

Token Test scores was associated with more intense therapy.

Unfortunately, analysis using the FCP did not yield a

similar pattern. Although Brindley et al5 noted significant

between-group differences in their study, there was no sig-

nificant difference in groups’ scores of the negative trials

versus the positive study. It should be noted that although theFCP is a widely used assessment of functional language, it is

a rather subjective instrument consisting of interviews and

observations of patients.

Constraint-induced (CI) aphasia therapy has as its hallmark

feature intense therapy for patients suffering from aphasia.

The use of intensive practice for short time intervals is

preferred over long-term, less frequent training in CI aphasia

therapy. The impact of intense therapy using the CI paradigm

was demonstrated by the Pulvermuller et al17 study, in which

patients receiving CI therapy (3 hours of therapy per day for

2 weeks) significantly improved on all outcome measures

compared with the patients receiving conventional therapy

who showed no significant improvement.

Earlier researchers have observed the association between

intensive therapy and improved aphasia outcomes. Brindley

et al5 noted that “it is only by radically reorganizing current

provision or increasing the time allocated to speech therapists

that their expertise can be effective in the field of chronic

aphasia.” In support of that statement, Poeck et al6 noted that

aphasia improved even in the chronic phase with intensive

therapy.The impact of the intensity of SLT on aphasia recovery still

requires further study. Most of the limitations of the present

review stem, in part, from the limitations of the original

studies. Only 3 studies were rated to be of “good” quality

(PEDro score6), whereas the rest were either of fair quality

(PEDro scores4 and 5) or did not qualify for a PEDro

rating6 because of a lack of randomization of the groups. The

use of nonstandardized measures and lack of clarity regarding

therapy intensity and the nonreporting of overall mean

changes in scores for outcomes measures were noted in

several studies. In addition, many of the studies were under-

powered with small sample sizes. The largest trial, Lincoln etal,11 randomized 327 patients; however, only 161 completed

analyses were reported, and only 27 patients received 36

treatment sessions.

Given the association between intensity of SLT and apha-

sia recovery, greater attention needs to be given to structuring

the most appropriate treatment regime. Length of therapy and

hours of therapy provided per week that allow for maximum

recovery require further investigation. Most importantly, this

review underscores the importance of SLT to aphasia recov-

ery. Previous highly influential studies such as Lincoln et al11

have led to doubt as to the efficacy of SLT in aphasia

recovery. Our review confirms that lower-intensity therapy

provided over a longer period of time does not result in asignificant change in outcome. However, more intensive

SLT, delivered over a shorter period of time, results in

significant improvement in outcome. We conclude that inten-

sive aphasia therapy delivered over 2 to 3 months is critical to

maximizing aphasia recovery, and failure to provide it poten-

tially compromises individual outcomes.

AcknowledgmentsThis study was funded by the Heart and Stroke Foundation of

Ontario, the Ontario Ministry of Health and Long Term Care, the

Parkwood Hospital Foundation, and the Canadian Stroke Network.

We thank Norine Foley, project coordinator, for her help with article

selection and data abstraction, and James Fisher for reviewing thisarticle. The following individuals were involved in assessment of the

TABLE 4. Association Between Intensity of Therapy and

Improvement in PICA and FCP Scores

Length of

Therapy

Hours of

Therapy per Week

Total Hours

of Therapy

PICA r 0.948 r 0.957 r 0.958

P 0.0001 P 0.0001 P 0.0001

Token Test r 0.581 r 0.811 r 0.963

P 0.171 P 0.027 P 0.0001










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